Worcester County Local Health Improvement Process

Public Health Assessment and Wellness

Video - DOT for 3HP TB Infection Treatment

State: KS
Type: Model Practice
Year: 2016

ABSTRACT:

The 3HP treatment for TB Infection requires once weekly, directly observed therapy (DOT) for 12 weeks. Following a large contact investigation at a local high school, the Health Department had 26 students and social contacts of the active case who tested positive for TB Infection and chose to receive the 12 week - 3HP treatment. Health Department resources were strained in trying to meet the demand of the normal TB client caseload, the ongoing contact investigation, the need for community wide education, the number of individuals who tested positive for TB Infection, follow-up medical exams and chest x-rays for those that chose to follow treatment recommendations. In order to meet the needs of the individuals who tested positive and to reduce costs associated with the treatment process, the Health Department asked our State TB Controller for permission to utilize Video-DOT for those requesting the 12 week - 3HP treatment regimen. Permission was granted, procedures written to meet the requirements of the 12 week treatment, equipment was purchased for use by those who did not have the necessary video capabilities and the process was initiated with clients who met the eligibility criteria and wanted to participate in video-DOT monitoring. While video medication monitoring has been utilized in the past, this is the first time it has been used for 3HP clients. Of the 14 individuals who started the 3HP video DOT, 13 completed treatment utilizing this practice.

ORGANIZATION:

Johnson County Department of Health & Environment

TITLE:

Video - DOT for 3HP TB Infection Treatment

Johnson County Department of Health and Environment is located in northeast Kansas and serves approximately 560,000 residents.
Following a large contact investigation at a local high school, 26 individuals with TB Infection chose the 12 week- 3HP treatment regimen, thus significantly increasing our caseload as a LHD.
Our objective was to provide an efficient, client centered approach to treatment for individuals with TB Infection. This approach minimized interruptions to their academic and extra-curricular programs; therefore, increasing compliance.
Permission was obtained from the State TB Controller to initiate video-DOT (VDOT) for those who were receiving treatment for TB infection with the 3HP regimen. While VDOT had been used for clients receiving treatment for active TB disease, it had not been used for 3HP treatment. Procedures were written and reviewed by the County's Legal Department and the State TB Controller, education and equipment (as needed) were provided to the individuals requesting VDOT monitoring and the process was initiated and completed with great success. Client eligibility was reviewed by a minimum of two TB program staff members to determine if the client met established criteria. To begin this treatment the client agreed to: obtain baseline laboratory testing prior to initiation and complete the first four doses at the health department, have labs drawn at their fourth appointment, where medication for VDOT was provided. The client returned to the clinic for their eighth and twelfth dose for clinical evaluation and routine laboratory testing.
Results/Outcomes
26 students chose the 3HP treatment. 14 of the 26 students opted for the VDOT.
13 out of 14 who started the 3HP treatment using VDOT completed the 12 week regimen. The individual that did not complete was due to an adverse reaction to the medication.
Routine medication management with the traditional face to face DOT would have cost the department roughly $5,200.00.
Utilizing VDOT with 6 in office visits and 6 VDOT visits per client resulted in cost savings of an estimated $2,066.00 for the 14 students who opted for the 3HP treatment.
The successful outcomes achieved by the utilization of this practice were dependent on the following factors:
Nurses provided a high level of TB education to the high school staff, students, parents and the community prior to test date
Education included:
Testing process
Significance of results (i.e. positive results, negative results without retest, negative results with need for a retest due to timeline of exposure)
Timeline between identification of TB infection and initiation of treatment
Medication regimens
Side effects associated with the medication regimen
Nurses provided timely notification of results and further instructions for evaluation
Nurses offered flexible scheduling to accommodate client needs; this included accepting VDOT calls outside of normal work hours
Continued education was provided throughout treatment as needed
Through patient education, flexible scheduling and the innovative use of VDOT, we were able to successfully provide treatment and client monitoring throughout spring break, summer break, international travel, and family relocation. Because of the success of the VDOT program; Health Departments throughout the state and the country have requested the procedures utilized in this process to initiate the practice in their local jurisdictions.
http://www.jocogov.org/dept/health-and-environment/home

TB infection treatment is difficult to initiate because clients are not symptomatic and often do not understand the importance of treatment. In the past, available treatment regimens have required clients to take medication for up to 9 months. Lengthy treatment regimens often include lifestyle restrictions, such as avoidance of alcohol or certain over-the-counter medication. While 3HP is a shorter treatment option, it historically has included weekly clinic visits which are time consuming and inconvenient to the client.
The target population is the 26 positive contacts who chose the 3HP treatment option; 54% chose VDOT.
In the past, education was provided related to the need for treatment and all available treatment options. Clients were encouraged to pursue treatment, but schedules, lifestyle restrictions and the time constraints of numerous visits to the health department and lengthy treatment regimens frequently prevented them from doing so.
The current practice of VDOT facilitates completion of treatment in a timely manner with minimal interruption to client's lifestyle. VDOT also offers a method of treatment that is familiar to the younger generation who are technologically savvy, yet easy enough to use for those who are not.
VDOT reduced:
Client travel time
Staff travel time and mileage reimbursement
Staff clinic time
Likelihood of non compliance
Missed or rescheduled appointments
Therefore making this a more convenient and favorable treatment option.
VDOT for the 3HP treatment regimen is innovative in that it utilizes the current VDOT practice used in the treatment of active TB Disease and applies it to the treatment of TB Infection. This new application of an existing practice allows flexibility for both staff and client, while minimizing interruption to the client's everyday life. VDOT increases the ability of TB staff to double the clients seen with little disruption to normal case loads.
The following links are related to VDOT studies and presentations by experts in the field of TB treatment. Information was gathered from pilot projects that demonstrated evidence of successful outcomes in the treatment of active TB disease to formulate the procedures utilized in implementing the 3HP VDOT program JCDHE utilized in treating clients with TB infection.
The International Journal of Tuberculosis and Lung Disease Volume 19, Number Feasibility of tuberculosis treatment monitoring by video directly observed therapy: a binational pilot study http://www.ingentaconnect.com/content/iuatld/ijtld/2015/00000019/00000009/art00011
Video Directly Observed Therapy (VDOT) for Monitoring Tuberculosis Treatment Adherence --- Richard S. Garfein, PhD, MPH UC San Diego, School of Medicine rgarfein@ucsd.edu http://action.lung.org/site/DocServer/Dr._Garfein_VDOT_Lecture_for_RD-TB_Durham_8-12-15_draft.pdf?docID=35881
STRATEGIES & APPROACHES FOR VIDEO-BASED DIRECTLY OBSERVED THERAPY (DOT) - Rutgers University http://web.njms.rutgers.edu/ntbcweb/courses/2014/Video%20DOT%20Webinar/Final%20Slides%204.30.pdf

The goal was to provide an efficient, client centered approach to the treatment of individuals with TB Infection. This approach minimized interruptions to their academic and extra-curricular programs; therefore, increasing compliance.
Initially, following identification of a positive case of TB disease in an area high school, the Health Department conducted a contact investigation and performed Interferon-Gamma Release Assays (IGRAs) on those identified as at risk of exposure. The school served as a platform for student, staff and community education and on-site testing. Media releases were utilized as an outlet for reaching those who were unable to attend a education session at the school. Kansas Department of Health and Environment (KDHE) offered guidance in establishing criteria for testing and Qiagen provided testing supplies free of charge. The three testing dates involved multiple partners/agencies in coordinating notification of those to be tested, distribution and completion of the necessary paperwork, blood draws, transporting and processing specimens and reporting of results. Permission was obtained from the State TB Controller to initiate video-DOT (VDOT) for those who are receiving treatment for TB infection with the 3HP regimen. While VDOT had been used for clients receiving treatment for active TB disease, it had not been used for 3HP treatment. Procedures were written and reviewed by the County's Legal Department and the State TB Controller, education and equipment (as needed) were provided to the individuals requesting VDOT monitoring and the process was initiated and completed with great success.
Client eligibility was reviewed by a minimum of two TB program staff members to determine if the client met established criteria.
Criteria:
obtain baseline laboratory testing prior to initiation and complete the first four doses with no complication at the health department
have labs drawn at their fourth appointment, where medication for VDOT was provided. The client must agree to return to the clinic for their eighth and twelfth dose for clinical evaluation and routine laboratory testing.
client must not be considered at risk for poor adherence (homelessness, substance abuse, psychiatric illness, reduced mental capacity, memory impairment)
client must be motivated to complete treatment
client must speak language VDOT staff can accommodate
client must be able to accurately ID medication
client must have access to VDOT device (health department can provide iPad if needed) and demonstrate proper use
client must have a physical setting for confidential communication
Time-frame: 12 weeks from initiation of treatment
Johnson County Department of Health and Environment (JCDHE) collaborated with school personnel to identify contacts to the active case, plan and implement on-site educational opportunities for staff, students, parents and the general public, and on-site testing of the identified contacts. JCDHE also worked closely with the school's media staff to prepare joint press releases to ensure consistent messaging went out to the public. Other partners included; outside physicians and clinics who did testing for students who were unable and unwilling to attend mass screenings opportunities, Qiagen who provided IGRA supplies and staff to help with the initial processing of the blood samples, Kansas Department of Health & Environment (KDHE) who provided staff to assist with lab draws and the final specimen processing at the State's lab, and Shawnee Mission Medical Center and Alliance Radiology who provided chest x-rays and readings at a reduced rate. These relationships with our community partners reduced expenses related to the contact investigation and increased testing and treatment compliance.
Start up costs for the VDOT process were relatively minimal. We purchased approximately $1200.00 worth of Apple iPads and associated accessories to be used by clients who did not have their own devices. We were able to use Preparedness dollars for a portion of these expenses as we are also able to use the iPads for Ebola client monitoring. In this instance all of the students had their own devices so there would not have been any expenses necessary for start up.
Regular meeting with school nurse coordinators; offers training and resources to county clinics, physicians, schools, health care providers, These regular meetings and trainings

Objective: To provide an efficient, client centered approach to treatment for individuals with TB Infection.
The use of VDOT was very successful in facilitating treatment of TB infection in cases identified through a contact investigation at a local high school. The objective in utilizing this method of DOT was to provide an efficient, client-centered approach to the treatment of individuals with TB infection with minimal interruptions to their academic and extra-curricular programs; therefore, increasing compliance and treatment completion.
When given as an option, the majority of clients chose the 3HP regimen as their treatment option and also chose to complete their treatment using the VDOT option. All individuals who chose VDOT were compliant with medication and only 1 individual stopped treatment (this was due to an adverse medication reaction).
Using VDOT for 3HP has resulted in fewer missed appointments/cancellations, therefore increasing the efficiency of the TB program. Clients find 3HP to be a flexible option that has minimal impact on their normal weekly schedules. VDOT provides TB staff more free time to perform other essential duties. VDOT saves both time and money while increasing the overall productivity of the clinic TB staff.
Evaluation of Practice:
Primary Data Source – TB staff, EpidemiologyPerformance Measures Used – To date the participation, compliance and treatment completion rates are being used.-93% of the initial group participating in VDOT completed the 12 weeks 3HP treatment.
Evaluation of the VDOT process in 3HP treatment is ongoing so as to include a larger number of participants and to include participants from the general population who may have different needs related to scheduling and knowledge of technology when compared to high school students.
Since the implementation of this practice, no modifications have been made. Ongoing evaluation of this practice may result in changes to the process as we broaden the populations served by the VDOT method of medication monitoring.

Lessons learned in relation to practice:
Reliable internet capabilities (i.e. no dropped calls/freezing picture)
VDOT can increase access to, as well as compliance with treatment for TB infection
To date, the practice of VDOT for 3HP treatment has been used for a very specific client population; in the future adaptations may need to be made for those with limited access to Wi-Fi and/or limited knowledge on available technology
Lessons learned in relation to partner collaboration:
In order to develop the current practice for 3HP VDOT, it was imperative to establish open communication between staff at JCDHE, KDHE, County legal representatives, and others to ensure that the practice developed would serve the client and public health needs while continuing to meet privacy standards as outlined by HIPAA.
Collaboration with primary care physicians was crucial to provide awareness that a mutual client was being treated with 3HP using VDOT. This collaboration was necessary to ensure that a medical doctor would be available to assess the client should they develop a medication reaction and need quick follow-up by their physician.
Several clients are in the final stages of various treatment regimens as part of the overall contact investigation. Final cost/benefits analysis is currently being performed and will be finalized once the clients have all completed treatment.
Our stakeholder’s are committed to the use of this technology due to ease of use and the flexibility that it allows for staff and participants.
Sustainability plans:
Continue to use Apple iPads for VDOT. This technology will be maintained through software updates in the coming years.
In the future, VDOT will be re-evaluated as new technology resources become available.
The practice will require regular reviews to ensure that the current practice continues to meet the needs of the client while continuing to be HIPPA compliant.
The staff at JCDHE is committed to sustaining and improving upon current 3HP VDOT practices. Improving access and flexibility of scheduling to better meet the needs of an ever-changing population.

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